darkhorse
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A 56-year-old man is admitted to the intensive care unit for acute respiratory distress syndrome (ARDS). The patient was transferred from an outside hospital today after a 2-week hospitalization for pneumonia. During that time, the patient's pulmonary status continued to deteriorate. One week ago he was intubated and placed on mechanical ventilation and over the past week, his oxygenation has worsened with a PaO2 of 66 on an inspired concentration of 100% oxygen. The patient has no other medical history except for rheumatoid arthritis. On transfer to the ICU, the patient is intubated and sedated on a mechanical ventilator. His chest radiograph shows patchy, bilateral, diffuse interstitial infiltrates. The most important intervention that will most benefit this patient is to
A. keep the patient in a prone position during mechanical ventilation
B. keep tidal volumes greater than 15 cc/kg
C. limit peak inspiratory pressure to 45 cm H2O or less
D. limit PEEP levels to less than 10 cm H2O
E. limit tidal volume to 6cc/kg
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| Kamsi
Forum Guru
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E
Low tidal vol 6mls/kg to maintain oxygenation n ventilation.If d O2 cannot be kept above 90% then PEEP 2-3cm .
Severe persistent hypoxaemia....prone positioning of pt
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| drdg
Forum Senior
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I have no idea about this question.
What is the answer? darkhorse
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| jvo_md
Forum Senior
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I go with D
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| doyoudig
Forum Guru
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E. limit tidal volume to 6cc/kg
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| cool doctor
Forum Junior
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the most important step in ARDS managment is the PEEP but we may need to raise it over 10 if persistent hypoxemia.
so I think E
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| darkhorse
Forum Elite
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The correct answer is E. Although once limited to very specialized care units, patients with ARDS are becoming more prevalent in general medical ICU settings, in part due to the increasing incidence and recognition of the disorder. ARDS is an inflammatory condition of the lungs of unknown etiology but is associated with many conditions such as pneumonia, trauma, sepsis, and blood transfusions. The common denominator of all ARDS is profound hypoxia defined as a PaO2/FiO2 ratio of less than 200. Because of the profound hypoxia, the patients require mechanical ventilation for improvement. Ironically, many of the strategies employed over the years have actually contributed to or significantly worsened the injury of ARDS. The only effective intervention to date was recently shown in an NIH clinical trial. The mortality benefit conferred from this maneuver is substantial. The limitation of tidal volume to 6cc/kg or less is now standard of care and is required knowledge of any physician caring for critically ill patients.
Although there have been case reports that prone positioning during mechanical ventilation (choice A) is useful for these patients, the randomized trials indicate that there is no mortality benefit associated with this intervention.
The traditional teaching of keeping tidal volumes greater than 15 cc/kg (choice B) and of limiting peak inspiratory pressure to 45 cm H2O or less (choice C) is now incorrect and in fact, has been shown to be very detrimental to these patients. Experimental data have shown that ventilatory strategies that overdistend parts of the lung or allow the lung to cycle repeatedly between a collapsed state and an open state can lead to injuryXso-called ventilator-induced lung injury. PIPs should be limited to 35 cm H2O or less.
Limiting PEEP levels to less than 10 cm H2O (choice D) is opposite of what is required to manage these patients. PEEP values often exceed 10 cm H2O so that repeated cycling between a collapsed state and an open state is prevented. This is the so-called "open-lung" approach to ARDS management.
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| drdg
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Thank you
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| tamerbashir
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THIS IS VERY HIGH YILDDDD!!!
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| darkhorse
Forum Elite
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is it not!!!
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| plastic_surgery
Forum Junior
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ARDS definitely is very very high yield for both step 2 ck and 3.
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